Survivors of natural disasters who have penetrating wounds may be at risk for necrotizing fungal infections, a series of cases in Joplin, Mo., showed.

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Survivors of natural disasters with penetrating wounds may be at greater risk for necrotizing fungal infections, a study found.

Note that the risk of mucormycosis infection among injured survivors was elevated twofold for each additional wound for which a patient was afflicted.

Survivors of natural disasters who have penetrating wounds may be at risk for necrotizing fungal infections, researchers found.

A case-control study of survivors of a category-5 tornado found that patients with penetrating trauma were at a nearly nine-fold risk for mucormycosis by Apophysomyces trapeziformis infection (aOR 8.8, 95% CI 1.1 to 69.2), according to Benjamin Park, MD, of the CDC, and colleagues.

Risk of infection among injured survivors was elevated twofold for each additional wound with which a patient was afflicted (95% CI 1.2 to 3.2), they wrote online in the New England Journal of Medicine.

The authors noted that mucormycosis is a rare infection by molds -- including Apophysomyces trapeziformis -- common in soil and decaying wood and with an affinity for iron-rich and acidic environments. Infection with these fungi generally only affects immunocompromised patients, but can also occur "after trauma in immunocompetent persons."

"A classic feature of mucormycosis is tissue necrosis as a result of vascular invasion and subsequent thrombosis," they added.

Park and colleagues followed 13 patients injured during a category-5 tornado in Joplin, Mo., on May 22, 2011, who had necrotized soft tissue due to mucormycosis, and 35 control patients who were injured in the tornado but were otherwise healthy.

Wounds were counted, classified as punctures, lacerations, or abrasions, and categorized as blunt or penetrating. Patients affected with mucormycosis had samples taken, which were cultured or DNA-sequenced to identify the source of infection. All 13 patients tested positive for A. trapeziformis.

Control patients were age 14 or older, had been hospitalized for skin-breaking injuries sustained during the tornado, and did not have clinical or laboratory evidence of mucormycosis.

Case patients had a median age of 48 (range 18 to 76) and a median five wounds (range one to seven). More than half of the case patients were female (54%), most required admission to an intensive care unit (77%), most had one or more fractures (85%), most had blunt trauma (69%), and more than a third had penetrating trauma (38%).

The authors also noted that "all case patients had been located in the most severely damaged zone."

The case and control patients did not significantly differ in age, sex, race, or by underlying medical conditions.

Patients with mucormycosis "underwent irrigation and extensive surgical debridement" and received systemic antifungal therapy for the incident wound at a median half-day from time of infection (range 0 to 7 days).

Five patients died within 14 days of wound culture with an active fungal infection. However, "autopsy was not performed in any of the case patients who died, which made it difficult to determine conclusively whether these deaths were primarily due to mucormycosis," they wrote.

Compared with controls, case patients were:

More than seven times more likely to be admitted to the intensive care unit (aOR 7.3, 95% CI 1.7 to 31.8)

More likely to have significantly more wounds (five versus two, P<0.001)

More likely to have puncture wounds (OR 9.1, 95% CI 1.8 to 45.7)

More likely to have penetrating trauma (OR 6.7, 95% CI 1.3 to 33.9)

Nearly seven times more likely to die (OR 6.7, 95% CI 1.3 to 33.9)

The elevated odds of dying did not remain significant when the number of wounds was controlled for.

Infection was independently associated with number of wounds and penetrating trauma, the authors noted.

They concluded that "increased awareness of fungi as a cause of necrotizing soft-tissue infections after a natural disaster is warranted."

Park and colleagues added that the FDA had, at the time of the study, only approved two anti-fungal agents (amphotericin B and posaconazole) for use against mucormycetes, making identification of mold affecting a patient crucial in treatment.

The study limitations included recall bias in self-reported data, absence of mild or undiagnosed mucormycosis data, small sample size, and lack of a validated injury-severity score.

The authors declared no conflicts of interest.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner